2017 HSC Section 2 - Practice Management

Cochran and Elder

Disruptive Surgeon Behavior

J Am Coll Surg

described being told, “You’re killing the patient!” and 3 mentioned instances when surgeons had said to them, “You’re an idiot!” Interviewees reported that these verbal out- bursts and comments created anxiety and discomfort in the operating environment, as well as fear of escalated behavior. Physical tantrums, manifested by throwing of objects or hitting or kicking walls or equipment (eg, buckets, tray stands, etc), were another common form of disrup- tive behavior and reported by 12 participants. Throwing was typically preceded by yelling, with subsequent throwing of a nearby object or an object already in the surgeon’s hands. For example, interviewees recounted in- stances when frustrated surgeons threw cell phones, pagers, scalpels, or medical supplies into the air, toward the wall, or on the floor. Participants also described in- stances when these objects veered or bounced and inad- vertently hit others in the room. Respondents perceived tantrum throwing as resulting in more errors in a surgical procedure and escalating demonstrations of anger. In the most grievous reports, 7 participants described cases of physical assault, including being pushed, grabbed, jabbed, hit, or having objects thrown directly at them. These de- scriptions involved being yelled at when being grabbed by the arm, or yelled at and then hit on the back or side. Nine interviewees described situations in which their concern for patient safety directly conflicted with the desire of the surgeon to efficiently complete the case. This included times when staff was concerned the patient was at a high risk for morbidity and/or harm, when there was doubt as to whether the case should proceed as planned, or when taking precautions that the surgeons believed were unjustified. Interviewees reported being in a difficult position when they wanted to stand up for the patient in the face of opposition from the surgeon who was preoccupied with time pressures. For example, all anesthesiologists reported being pressured to admin- ister more anesthetic than was safe or necessary during moments when surgeons attributed difficulties to a need for additional sedation. Participants also described occa- sions when surgeons insisted that multiple cases could be done simultaneously and that they, therefore, should have access to more than one operating room and team. Another form of disruptive behavior was refusal to work with unfamiliar staff or with staff in training. Seven interviewees reported that surgeons demanded to work with the same staff each day, and when new staff was assigned to the operating room, surgeons would berate them, resist their help, or stop the surgery. Interviewees indicated that they believed that working with established staff allowed for greater familiarity, expediency of communication, and avoided the additional effort of training by the surgeons.

and analysis became more complex (eg, categories were redefined to include various subcategories). The cate- gories evolved, eventually forming a theory of partici- pants’ experiences. 15 Finally, in selective coding, an overarching theory was determined, based on a core cate- gory that subsumed all others, and on the relationships between different participants’ experiences. 6,15 The result was a 4-component model of these experiences. RESULTS All 19 participants worked in the perioperative environ- ment of the same academic medical center at the time of their interview in 2012. In terms of occupation, 5 par- ticipants were medical students, 4 were anesthesiology faculty members, 4 were general surgery residents, 4 were perioperative nurses, and 2 were scrub technicians. Demographics of participants are documented in Table 1 . The following 4 themes about the disruptive behavior of surgeons were indicated through data analysis, partici- pant checking, peer debriefing, and examination of the audit trail: categories of disruptive behavior, situational stressors, cultural conditions, and personality traits. Categories of disruptive behavior Participants observed a range of behaviors that were disrup- tive to the surgical environment, the most common of which was verbal hostility (see Table 2 ). Fifteen interviewees reported instances in which they witnessed a surgeon demon- strate verbal hostility by “yelling,” “swearing,” making “offensive comments,” “blaming” others for difficulties, “threatening,” or making “disparaging remarks” about others’ capacities. Interviewees described the aim of this hos- tility was to berate, intimidate, cause a feeling of deficiency, or evoke a sense of shame. For example, 3 interviewees

Table 1. Interviewee Demographics Demographics Age, y, median (IQR)

33 (28 ! 44)

Sex, n

Male

9 9

Female

Race, n

White

13

Asian American

4 1 1 2 9 8

Hispanic

African American

Highest level of education, n Some college/associate’s degree

Bachelor’s degree

MD

IQR, interquartile range.

46